Table 2.

Process of formulating meanings and clusters for the Aboriginal and Torres Strait Islander hospital liaison officers (ATSIHLOs).

Location of significant statement	Statement (quotes)	Formulated meanings	Theme cluster	Theme [T]
ATSIHLO6003 P5	“You know, in communication barriers sometimes to it”s a matter that doctors need to really listen. Sometimes you get doctors who think they know better that the patient, but no one can know what someone else”s pain is because they”re not living in their body, are they?”
ATSIHLO6001 P2	“And most of the patients would turn around and say, you know, like I“ve told them how I”m feeling but I feel as if I don’t get heard.’	Patients are not heard/not listen to
P3 P3	‘The health professionals, they never listen. It's like he (‘patient’) says as if they (‘health professionals’) think “I”m imagining it” or or, you know, like that sense, that he (‘patient’) feels there's no help at the hospital. So every time he (‘patient’) comes here, it's like he's expecting that from consultants that they won’t listen to him.’ ‘The patient said to me: ‘I just I just want them to listen to me. I just want them to look into it like why I’m having all this pain.’		ATSIHLOs promote patient engagement with the service. ATSIHLOs provide support, validation and comfort for patients	Role of ATSIHLOs [T1]
ATSIHLO6003 P1	‘Patient becomes unable to advocate for themselves when they’re in pain.’
P3 P7-8	‘I think is the most frequent issue (‘pain relief’) on which I experience a patient needs advocacy, on every single care, they are not complaining for nothing.’ ‘Early years when I came here, Aboriginal people were less likely to present to hospital when they’re not well and they’d only come when seriously ill. But that has improved over the years, and we hope that it's because they know that they got us to lean on when they come in.’	ATSIHLOs are the voice and empowerment of patients (Patients in pain cannot advocate for themselves) & offers support
ATSIHLO6003 P3	‘There was an argument there between the patient and an ED nurse over the issue of, you know, whether or not she actually had this pain.’
P5 P7	‘…And there's another issue that comes up, too, is sometimes when the patients are asking for stronger pain relief, there's this issue that whether the drug seeking or genuine.’
R4 P9	‘At the same time, they (‘patients’) might feel a bit of a cringe factor when they’re talking to doctors. All right. It's a case of what is this doctor going to believe? What I’m saying? Am I? Am I being a winger or those kind of factors?’ …’when it comes to pain, there's almost a blanket notion sometimes that you're only here for certain things. And, you know, from my personal experience, it was actually quite insulting to have this insistence that I was here, for particular reasons when I was actually generally unwell and in extensive pain…. I think that that again, comes down to racist preconceived ideologies that you know, sometimes we carry subconsciously.’	Credibility/stigma/validation/apprehension about the information provided: is it genuine?
ATSIHLO6003 P6	‘But she (‘patient’) comes in always wanting (‘medication’), you know, she got very offended when I first met her about the fact her management plan referred to her opioid dependence. So I had to talk to the clinical care coordinator for the ED and said: look, you just going to have to use a different language because the impression the patient has is that you’re calling her - drug seeking.’
P8	‘Talking to doctors, doctors need to be very careful to avoid any sense, any intuition, intuitive feeling of being judgemental about the way the person lives their lives.’	The language used and how messages are delivered by clinicians	The elements involved when communicating with Aboriginal and Torres Strait Islander patients	What is communication [T2]
ATSIHLO6001 P4	‘Okay, they (‘patients’) will say yes, yes. But afterwards, the consultant goes, the patient will turn around and say to me, I didn’t understand a bit. I don’t know what he (‘consultant’) is talking about. So then I have to explain.’
P4 P5	‘Because the communication side of it, sometimes they (‘health professionals’) will not ask the questions directly. Others do, others don’t.’ ‘Because sometimes I (‘ATSIHLO’) go back to the consultant and I (‘ATSIHLO’) tell the consultant if I (‘ATSIHLO’) was to explain what you've just said in there to the patient. In simple terms, because they (‘consultants’) are asking questions or not understanding how to ask questions; how would you (‘consultant’) want me (‘ATSIHLO’) to explain? How would I (‘ATSIHLO’) say it? Yeah, sometimes I
	(‘ATSIHLO’) have to go back to the consultant because it's depending of the importance. The message they’re trying to get across.’	ATSIHLO: not just verbal but visual (P15, P16, P17), tone (P6, P7, P8, P17), body language (P4, P5, P6, P7, P8, P12, P13, 17) and emotional P17
R4 P8	‘One patient in particular, it was almost, because she, she presented so frequently. It's like, she could read everyone straightaway, you know, she wasn’t being taken seriously. And that's in spite, you know, whatever treatment she's getting through the clinic. But I feel like, again, with the tone and the body language, she's reading it straightaway, as soon as she's coming in.’
RI2 P17	‘I think we agree that communication is about building rapport, it's about knowing the individual as they are and getting to know that person. We agree that communication is not just verbal, it's visual and it's a body language, a physical thing, and it's an emotional thing. Your tone of voice.’
R3 P6	‘It's the tone that you know, they might be saying something nice, but how they deliver that message. Yeah, sometimes it was bossy, or really abrupt.’
ATSIHLO6001 P4	‘You know, sometimes, sometimes just for the sake of it, or sometimes they will say, yes, you know, understood where there is a doctor telling them their medical condition. Okay, they (‘patients’) will say yes, yes. But afterwards, the consultant goes, the patient will turn around and say to me, I didn’t understand a bit. I don’t know what he (‘consultant’) is talking about.’	Cultural factor affecting communication	Cultural factors: Not asking questions Against confrontation Too impersonal Protocols Preferences
P5	‘…Sometimes it's that shy factor, they (‘patients’) will shy away, especially when they’re not comfortable; they’re not comfortable as it is in this environment. So they’ll sort of withdraw a bit.’	Cultural and environmental factors affecting communication
P9	‘So it's a bit some of the Indigenous families of patients that come in. When you go straight into business, they switch off straight away. If you’re talking about something that they don’t understand. There's no one there for them to explain as the doctor is going along. They’ll switch off and they will just say that yes, yes, yes, thing just so the doctor can go away.’	Cultural factor affecting communication	Historical factors: No challenge to authority Institutions are scary Consent
R1 P15 R1 P3 R4 P11 I2 P11 RI2 P10	‘A lot of people, they will come through us, and they won’t tell clinicians that they are in pain, but they’ll happily tell someone like us as a third party, that they are in pain. And that's is just the way sometimes Aboriginal and Torres Strait Islander people are, is that they’re happy to go through a third party to tell that they are in pain.’ ‘I experience a lot of Aboriginal and Torres Strait Islander people, especially a lot of our elders, who are looking after young children, they have a strong threshold of pain, because it's sometimes not their priority to, to come to hospital and deal with pain, if they can, if they can deal with that pain and the threshold of it.’ ‘The fact that a lot of missions and even up to the Torres Strait Christianity is even outside of just culture alone and you have to add a layer of religion where you know that Christianity tells them like this is inappropriate, I would prefer this sort of stuff. So those sensitivities on top of culture as well.’ ‘But I guess as Aboriginal and Torres Strait Islander people, we carry different things. Every human carries different pain. We have intergenerational trauma, we have that emotional pain. And when we learn in different families, we’ve learned different ways to manage our pain, a different way to respond to pain.’ ‘I think here is like, not disregarding that as well, like culturally, for me as a younger female speaking to an older male. I personally feel intimidated, because I feel like this is not business that I should be talking about…And so I went to the gentleman, I said, I know this is an uncomfortable situation for you. And I, and I wouldn't generally come and see somebody for this because of where I'm from. And so it doesn't sit right with me. But the doctor has this concern are you all right to chat about that. And in that instant, he was like, yes, that's okay, we'll yarn about it. And he was sharing, and I was sharing too, un-shamed. And so acknowledging that, that is a cultural thing, rather than just saying, Oh, you don't have, we don’t have a male here’.	Preference of communication Cultural factor affecting communication (Pain expression and not a priority) Religion factor affecting communication Historical factors and pain expression Cultural protocols and communication preferences that exist sometimes cannot be addressed but should be acknowledged. Patient have to agree/consent		Historical & cultural factors influencing communication [T3]
R1 P3 R4 P14 R4 P9	‘I think if we want if we want our Aboriginal and Torres Strait Islander people to be a part of pain clinic, and we need to share good stories that come out of pain clinic, you know that, because it's not really something like I said, that's known to the client cohort of our people. So sharing good stories about how pain clinic has actually helped and assisted these people. And sharing those stories could actually invite more Aboriginal Torres Strait Islander people into that environment, if that makes any sense.’ ‘What's the difference about pain management and the difference in the pain clinic to dealing with managing pain with medication? And I think a lot of our mob don’t know what the service delivery is in in pain clinics. So which makes them really apprehensive to attend.’ ‘A lot of it again is fear, which is why we have a lot of fail to attend outpatient appointments or pain clinic appointments because they (‘patients’) don’t know. They don’t have that understanding of why they should go or how it can better their lifestyle.’ ‘And it's not just having the training and cultural awareness training but ensuring that it's interwoven through you know, even their training as healthcare professionals, not just a once off once a year type of thing, it needs to be continuous. And it needs to reflect how, you know, the patients that they’re (‘healthcare professionals’) currently seeing and not just be like one stock standard training either.’	Informing and sharing good stories to bring people to the service Informing – increasing awareness about services and benefits - Literacy Informing – increasing understanding the benefits of attending services Healthcare professionals need to be aware and incorporated into practice	Information to improve health literacy to improve access to the pain clinic	Information and literacy [T4]